Provider Demographics
NPI:1144300906
Name:DORCHUCK MEDICAL INC
Entity type:Organization
Organization Name:DORCHUCK MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:DORCHUCK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:208-556-4803
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:OSBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83849-0596
Mailing Address - Country:US
Mailing Address - Phone:208-556-4803
Mailing Address - Fax:208-556-1023
Practice Address - Street 1:801 E MULLAN AVENUE
Practice Address - Street 2:
Practice Address - City:OSBURN
Practice Address - State:ID
Practice Address - Zip Code:83849-0596
Practice Address - Country:US
Practice Address - Phone:208-556-4803
Practice Address - Fax:208-556-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1871225100000X
IDM-6906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M580OtherBLUE CROSS
IDDD9081OtherMEDICARE RAILROAD
ID8M580OtherBLUE CROSS